Prevention and Management of Postprostatectomy Erectile Dysfunction

Context: Erectile dysfunction (ED) is the complication associated with radical prostatectomy (RP) for clinically localized prostate cancer that has the most negative impact. Currently, several therapeutic options are available to improve sexual health after surgical treatment. Objective: To critically analyze the factors affecting erectile function after RP and to evaluate the evidence suggesting the role of pharmacologic prophylaxis and treatment of ED after surgery. Evidence acquisition: This article is based on the proceeding of the Risk Evaluation and Mitigation Strategy (REMS) meeting held in Madrid, Spain, in 2007. Evidence synthesis: Several basic science reports have highlighted a potential role of phosphodiesterase type 5 inhibitors (PDE5-Is) in the prevention of endothelial damage related to ischemia-reperfusion and/or denervation following surgery. However, patient selection and preservation of both nerves and vascular supply integrity are the major determinants of postoperative erectile function. Pharmacologic treatment of postoperative ED, using either oral or local approaches, is effective and safe. Moreover, recent studies have shown that pharmacologic prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in post-RP patients has been shown to be highly effective. in this context, pharmacologic prophylaxis may potentially have a significant expanding role in future strategies aimed at preserving postoperative erectile function. Conclusions: Administration of pro-erectile drugs is the key factor of erectile function recovery after RP. Use of on-demand PDES-Is in post-RP patients has been shown to be effective and safe, with better results seen in select young patients treated with a bilateral nerve-sparing approach. Pharmacologic prophylaxis may have a role in the future. Large, multicentric, placebo-controlled trials are urgently needed in order to identify the best regimen for treating postsurgery ED. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.